Healthcare Provider Details

I. General information

NPI: 1942229281
Provider Name (Legal Business Name): JAMES FULLER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

659 S CENTRAL VALLEY HWY
SHAFTER CA
93263-2790
US

IV. Provider business mailing address

928 S FARRAGUT ST
RIDGECREST CA
93555-7508
US

V. Phone/Fax

Practice location:
  • Phone: 661-459-1900
  • Fax:
Mailing address:
  • Phone: 760-375-1330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18379
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: